A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.

Evaluate the firmness of the uterus (fundus).

Obtain a type and crossmatch.

Administer oxytocin infusion.

Initiate oxygen therapy by nonrebreather mask.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A.

Choice A rationale:

Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.

Choice B rationale:

Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.

Choice C rationale:

Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.

Choice D rationale:

Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.

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Correct Answer is ["A","E","F"]

Explanation

The correct answers are choices B, E, and F.

Choice A rationale:

Nausea with vomiting during the first trimester is a common symptom of pregnancy and does not need to be reported immediately to the health care provider.

Choice B rationale:

Sudden leakage of fluid during the second trimester could indicate premature rupture of membranes, which can lead to infection and preterm labor. This should be reported immediately.

Choice C rationale:

Urinary frequency in the third trimester is a common symptom of pregnancy due to the growing uterus putting pressure on the bladder.

Choice D rationale:

Backache during the second trimester is a common symptom of pregnancy as the body adjusts to the growing uterus.

Choice E rationale:

Lower abdominal pain with shoulder pain in the first trimester could indicate an ectopic pregnancy, which is a medical emergency and should be reported immediately.

Choice F rationale:

Headache with visual changes in the third trimester could indicate preeclampsia, a serious condition that can lead to seizures, stroke, and other complications. This should be reported immediately.

A. She did her perineal care independently. B. She is eager to talk about her birth experience. C. She has not asked for anything for pain all day. D. She sits and rocks her infant for long intervals.

Correct Answer is A

Explanation

The correct answer is choice A. She did her perineal care independently.

Choice A rationale:

Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.

Choice B rationale:

Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.

Choice C rationale:

Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.

Choice D rationale:

Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.

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A nurse is caring for a client who gave birth 2 hr ago.The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing a teaching plan for a pregnant woman about the signs and symptoms to be reported immediately to her health care provider.Which signs and symptoms would the nurse include? Select all that apply.

Correct Answer is ["A","E","F"]

Explanation

A nurse is assessing a postpartum woman.Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period?

Correct Answer is A

Explanation

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A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.